In Haiti, Bureaucratic Delays Stall Mass Cholera Vaccinations

Joseph Francis, 54, says he came to this cholera clinic in Haiti's capital, Port-au-Prince,after becoming so dehydrated he could barely walk. Cholera has killed more than 7,000 Haitians since the first outbreak of the disease in October 2010. At the start of the rainy season, cases are once again beginning to climb.

Cots are lined up in a Port-au-Prince cholera clinic run by GHESKIO, a Haitian medical group. GHESKIO is helping to organize a huge pilot project to vaccinate some 100,000 Haitians against cholera. Tens of thousands of people have signed up to participate. The health workers have been trained, and the vaccine is waiting in coolers. But the campaign is bogged down in bureaucratic red tape.

Residents of the Port-au-Prince slum Cite de Dieu step gingerly over a stream of sewage. Aid workers had planned to be finished with the vaccination program before the spring rains, when widespread flooding can bring cholera directly into people's homes.

Nadia Simone stands in front of her house in Cite de Dieu. She says she has been trying to get a trash-clogged ditch next to her house drained because she knows it brings cholera right to her doorstep. Last year cholera made her young daughter very sick. "I don't want cholera to come back to my house," she says.

A lone pig roots through trash along a sewage canal that runs from the center of Port-au-Prince through Cite de Dieu. During the rainy season, the canal overflows its banks and fills nearby houses with sewage.

A GHESKIO worker goes door to door in Cite de Dieu. As part of the planned vaccination campaign, an army of health workers has gone out to inform Haitians about cholera and sign them up to get the vaccine.

Most people in this rural part of Haiti, near Saint-Marc, get their water from the Artibonite River. Though the river is known to be contaminated with cholera, few can afford chlorine tablets to purify the water.

Esperante Jean-Louise, who goes by Fifi, got cholera last year. The experience was terrifying, she says: "I first felt it in my head. And then once I started vomiting, I had diarrhea at the same time. I couldn't stand up — I was near death."

Rice farmer Alexis Rochenel, Fifi's husband, shows his blank cholera vaccination card. People will need two doses of vaccine spread over several weeks. Health workers could have been finished with the first round of vaccinations by now. But they're still waiting for the government to sign off on the project.

A young girl cools off from the midday heat in an irrigation canal near Saint-Marc. People in this area were chosen for the pilot vaccination program because they draw their water from the contaminated Artibonite River.

A young girl bathes in an irrigation canal. The canal and nearby river are the primary sources of water for most people who live in the country around Saint-Marc, Haiti.

John W. PooleNPR

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Originally published on May 23, 2012 9:56 am

A hundred thousand people in Haiti are ready and waiting to get vaccinated against cholera.

The vaccine is sitting in coolers. Vaccination teams are all trained. Willing recipients are registered and entered into databases.

The impending mass vaccination project aims to show that vaccinating against cholera is feasible in Haiti. It has never been done in the midst of an ongoing cholera epidemic. So far, more than 530,000 Haitians have fallen ill with cholera, and more than 7,000 have died.

Rouzier works with GHESKIO, a Haitian medical group that is organizing the vaccination project in Port-au-Prince, Haiti's capital. The rural arm is sponsored by Partners in Health in the Artibonite River valley, where cholera first appeared.

The two groups have been planning the demonstration project for more than a year.

Initially it was opposed by a previous Haitian government, in part because international agencies such as the World Health Organization and Pan American Health Organization were against it. Officials at the U.S. Centers for Disease Control and Prevention also opposed it privately.

But the WHO last November approved the dollar-a-dose vaccine that is ready to be used in Haiti, the PAHO now favors the project, and the current government of Michel Martelly indicated approval in December. The CDC representative in Haiti says it's supportive and interested in the outcome.

Now the project is awaiting approval from a national ethics committee, which wants assurance that the vaccine is no longer considered experimental.

To show how the campaign would work — and why it's needed — Rouzier took an NPR team for a tour of the urban target area. It's called Cite de Dieu, or City of God.

A health worker meanders through the narrow streets with a bullhorn. "Avoid cholera!" she says. "Get vaccinated!" It's part of a awareness campaign that began in January.

Cite de Dieu is one of the worst slums in Port-au-Prince, with 40,000 people packed four and five per tiny room in dwellings made of whatever people can find.

"These are people who live in really subhuman conditions," Rouzier says as we hop over a ditch in the dirt street. It's filled with bilious, green water — an open sewer.

"When it rains, everything mixes. It becomes a soup," Rouzier says, "which is a perfect breeding ground for every diarrheal disease, cholera included. The houses get flooded, and people are up to their knees in water and they just have to wait for the water to recede."

Nadia Simone lives right next to this particular ditch. During last year's rainy season, her young daughter got very sick with cholera. So she has registered her family to get vaccinated.

"All my children will be vaccinated, because I don't want cholera to come back to my house," Simone says.

Almost everybody contacted by GHESKIO workers in a door-to-door campaign has said they want the vaccine. Their names, ages and addresses have been entered into smartphones and uploaded into a master data file. (First, the health workers had to paint house numbers next to each doorway, because there were no addresses.)

Everyone will require two doses of the oral vaccine over a period of two to three weeks, so it's important to keep track of who has had which dose.

Next, Rouzier takes us to a cholera treatment center. We wash our hands in chlorine water before and after entering a long army tent lined with cots. When we visit, there's only a single recovering cholera victim. But a year ago, this place was jammed with desperately ill patients.

Many of them were young and previously healthy. But cholera moves fast. Although it's easily treated, the diarrhea of cholera can kill within hours.

"It's shocking to see somebody die of dehydration," Rouzier says. "I saw a young 20-year-old collapse in front of me from paralysis because he had lost too much potassium. A healthy, strapping 20-year-old! This is unheard of!"

Some critics of the vaccination project say it's better to focus on providing clean water and toilets. Rouzier says Haiti has to do both.

"Fixing the sanitation problem and giving access to potable water is the answer," she says. "But let's be realistic. When is that going to happen? And how many people can we allow to die in the meantime?"

The tragedy is, cholera was unknown in Haiti until recently. Then, 10 months after the devastating earthquake of 2010, it appeared with explosive force.

It started up in the mountains of Haiti's central plateau, a three-hour drive from Port-au-Prince. The epicenter is a sleepy-looking United Nations encampment on the bank of a winding stream.

There is strong evidence that U.N. peacekeeping troops stationed there brought the cholera bacterium from Nepal. It spilled into the stream from a leaky latrine, and then flowed into the nearby Artibonite River, Haiti's longest.

The disease spread with astonishing speed. Within a week of the first case, Dr. Patrick Almazor says, seriously ill cholera victims were overwhelming the hospital where he works in Saint-Marc, a small city 50 miles downstream from the U.N. camp.

"I remember, the second day of the outbreak, we saw 800 patients here in this hospital," Almazor says. "There were patients everywhere."

Most of them came from tiny villages downriver from Saint-Marc. It's a beautiful countryside, crisscrossed by canals and irrigation ditches that nourish emerald-green rice paddies.

This is the other area chosen for the planned vaccination campaign. People here are at high risk for a new surge of cholera because they draw their water from the contaminated Artibonite.

"People here know they should be washing their hands with soap," says Jonathan Lascher of Partners in Health. "They know they should be drinking treated drinking water. They know they should be using latrines. But that's not always possible. It's not a question of ignorance; it's a question of access."

Vaccinating the entire population in this rural area will be very difficult. People are scattered across a broad area with wretched roads. As in Port-au-Prince, 50,000 people in the area have been registered for vaccination by health workers, their data entered into tablet computers.

Many villagers say they're eager to be vaccinated. They remember last spring's rainy season and the quick-moving disease it brought.

If the project does go forward, however, proponents will face another hurdle. As the Haitian proverb goes, there are mountains beyond mountains.

After all, the planned vaccination project will reach only about 1 percent of the Haitian population. To bring cholera under control, experts figure they'll need to vaccinate millions of people at high risk of cholera — before next year's rainy season.

This story was produced for broadcast by NPR's Jane Greenhalgh.

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

DAVID GREENE, HOST:

In Haiti, thousands of people are ready and waiting to get vaccinated against cholera. The vaccine is sitting in coolers. The teams are all trained. A hundred thousand people have signed up. It's a mass vaccination project, something that's never been done before in the midst of an ongoing cholera epidemic.

And there is growing urgency. Cases are beginning to climb with the coming of the rainy season. But as NPR's Richard Knox reports, the vaccination campaign is bogged down in bureaucratic red tape.

RICHARD KNOX, BYLINE: Cholera is an ancient disease people in developed countries haven't had to worry about since the 1800s, in the days before municipal water supplies and sewage systems. But here in Haiti, there are few clean water and sewage systems, and cholera is everywhere, especially in places like this. It's called Cite de Dieu - the City of God. It's one of the worst slums in Port-au-Prince, Haiti's capital.

UNIDENTIFIED WOMAN: (Foreign language spoken)

KNOX: A health worker with a bullhorn meanders through the narrow streets. Avoid cholera, she says. Get vaccinated.

People in this community are anxious to get vaccinated. More than 40,000 people are packed into tiny dwellings. No running water, no latrines. We hop over a ditch in the dirt street. It's filled with bilious green water - an open sewer.

Nadia Simone lives right next to it. Last year during the rainy season her young daughter got very sick with cholera.

KNOX: An army of health workers has already gone door-to-door, telling people the facts about cholera and the vaccine, painting house numbers above every door, entering everybody's name and age and willingness to be vaccinated into smartphones. And like Nadia Simone, almost everybody has said yes.

SIMONE: (Through translator) All my children will be vaccinated, because I don't want cholera to come back to my house.

KNOX: Our guide to the City of God is a young Haitian doctor named Vanessa Rouzier. She works with a medical group called Gheskio. It's organizing the vaccination campaign here. They had planned to be finished before the spring rains. That's when widespread flooding brings cholera directly into people's homes.

VANESSA ROUZIER: When it rains, everything mixes. It becomes a soup, which is a perfect breeding ground for every diarrheal diseases, cholera included.

KNOX: So you can't get away from it, basically?

ROUZIER: No, when it rains, the houses get flooded and people are up to their knees in water and they just have to wait for the water to recede.

KNOX: People will need two doses of the vaccine spread over several weeks. They could have been finished with the first round by now. But they're still waiting for the government to sign off on the project. Dr. Rouzier is frustrated by the delay.

KNOX: We wash our hands in chlorine water before going in. It's a long army tent lined with cots. At the moment, there's only one recovering cholera victim. But during last spring's rainy season, this place was jammed with desperately ill patients.

ROUZIER: It's shocking to see somebody dying of dehydration. I saw a young 20-year-old collapse in front of me because of paralysis because he had lost too much potassium. Healthy strapping 20-year-old, this is unheard of.

KNOX: Rouzier worries that if they don't start vaccinating soon, this tent will be full once again. Some critics of the vaccination project say it's better to focus on providing clean water and toilets to communities like this one. Rouzier says Haiti has to do both.

ROUZIER: Fixing the sanitation problem and giving access to potable water is the answer. But let's be realistic. When is that going to happen? And how many people can we allow to die in the meantime?

KNOX: The tragedy is, cholera was unknown in Haiti until recently. Then 10 months after the devastating earthquake of 2010, it appeared with explosive force. I asked our translator, Jean Magloire, to show me the place where it began.

(SOUNDBITE OF CAR DOOR SLAMMING)

KNOX: It's a 3-hour drive away, up in the mountains of Haiti's central plateau.

JEAN MAGLOIRE: This is where it all started, by dumping waste here from the U.N. camp.

KNOX: It's a sleepy-looking United Nations encampment on the bank of a winding stream. There's strong evidence that peacekeeping troops stationed here brought the cholera germ from Nepal. And it spilled into the stream from a leaky latrine, and then into the Artibonite River, Haiti's longest.

The disease spread with astonishing speed. Within a week of the first case, Dr. Patrick Almazor says desperately ill cholera victims were overwhelming the hospital where he works in Saint-Marc, 50 miles downstream.

PATRICK ALMAZOR: I remember the second day of the outbreak. We saw 800 patients in here in all this hospital, like every single footage.

KNOX: Patients everywhere.

ALMAZOR: Everywhere, everywhere.

(SOUNDBITE OF ROOSTER)

KNOX: Most of those patients came from tiny villages down-river from Saint-Marc. It's a beautiful countryside, criss-crossed by canals and irrigation ditches that nourish emerald-green rice paddies.

JONATHAN LASCHER: Right now we're at the base of the Artibonite, basically the mouth of the river where it meets the sea.

KNOX: That's Jonathan Lascher. He works for Partners in Health, a Boston-based group that's organizing the rural arm of the cholera vaccination campaign. This area was chosen because it's at high risk of a new surge of cholera since people here draw their water from the contaminated Artibonite River.

LASCHER: People here, they know they should be washing their hands with soap. They know they should be drinking treated drinking water. They know they should be using latrines. But that's not always possible. It's not a question of ignorance. It's a question of access.

KNOX: Vaccinating the entire population in this rural area will be very difficult. People here are scattered across a broad area with wretched roads. Health workers have already fanned out with tablet computers to take a complete census, sign people up, and give them blue vaccination cards.

ALEXIS ROCHENEL: (Through translator) This is my card.

KNOX: Rice farmer Alexis Rochenel is anxious to get vaccinated. Last year cholera hit his family.

ROCHENEL: (Through translator) My wife was sick. And she was treated at the hospital. I am going to call her for you.

KNOX: His wife, Fifi, is a slender woman wearing a brown turban. She says her brush with cholera was terrifying.

ESPERANTE FIFI JEAN-LOUISE: (Through translator) I first felt it in my head. I couldn't stand up. I couldn't stand up. I was near death.

KNOX: Although Fifi survived, more than 7,000 other Haitians have died of cholera so far. And well over a half-million have gotten sick.

There's hardly a village anywhere in Haiti that hasn't seen cholera. A previous Haitian government was against vaccination. The current government supports it. But one bureaucratic glitch after another has stymied the plan. If the project does go forward and shows that cholera vaccination is possible, proponents face another hurdle: expanding vaccination to millions of Haitians before next year's rainy season.

Richard Knox, NPR News.

GREENE: And Richard's piece on the cholera epidemic in Haiti was produced by Jane Greenhalgh.